What is the initial management for ankle fracture in the emergency department?

Initial Management of Ankle Fracture in the Emergency Department

Immediately assess for limb-threatening complications, apply the Ottawa Ankle Rules to determine imaging needs, obtain three-view radiographs if criteria are met, provide adequate analgesia, splint the ankle, and address any neurovascular compromise or open wounds emergently. 1, 2

Immediate Assessment for Life/Limb-Threatening Conditions

Vascular Compromise

• If the fractured extremity appears blue, purple, or pale, activate emergency response immediately as this indicates poor perfusion and represents a limb-threatening injury requiring urgent intervention 1
• Assess distal pulses (posterior tibial and dorsalis pedis arteries) and capillary refill 3

Open Fractures and Severe Bleeding

• Control life-threatening bleeding first using direct pressure; if unsuccessful, apply tourniquet per severe extremity bleeding protocols 1
• Cover open wounds with clean dressing to reduce contamination and infection risk 1
• Administer antibiotics immediately in the emergency room and continue for 48 hours 4
• Plan for urgent operative irrigation, debridement, and fixation within hours of presentation 4

Neurovascular Examination

• Document motor and sensory function before any manipulation 1
• Avoid manipulation of the ankle prior to radiographs unless there is neurovascular deficit or critical skin injury to prevent complications from re-manipulation 1

Application of Ottawa Ankle Rules for Imaging Decision

When to Obtain Radiographs

Order ankle radiographs if any of the following Ottawa Ankle Rules criteria are present: 1, 2

1. Inability to bear weight immediately after injury 1, 2
2. Point tenderness over:
   • Medial malleolus 1, 2
   • Posterior edge or inferior tip of lateral malleolus 1, 2
   • Talus 1
   • Calcaneus 1
3. Inability to ambulate 4 steps in the emergency department 1, 2

Ottawa Ankle Rules Performance

• Sensitivity of 92-99% for detecting ankle fractures, with 96.7% in recent validation 1, 2
• Correctly rules out fracture without radiography in 299 out of 300 patients 2
• Valid for adults and children ≥5 years of age 1

Exclusionary Criteria (Do NOT Use Ottawa Ankle Rules)

Obtain radiographs regardless of Ottawa criteria if: 1

• Neurologic disorder or peripheral neuropathy present 1
• Intoxication 1
• Distracting painful injuries 1
• Age <5 years 1

Radiographic Imaging Protocol

Standard Views Required

Obtain three standard views: 1

• Anteroposterior view 1
• Lateral view 1
• Mortise view 1
• Include base of fifth metatarsal distal to tuberosity 1

Weight-Bearing Radiographs

• Obtain weight-bearing views if possible to assess fracture stability, particularly for malleolar fractures 1
• Medial clear space <4 mm confirms stability 1
• Increased instability indicated by: medial tenderness/bruising/swelling, fibular fracture above syndesmosis, bi- or trimalleolar fractures, open fracture, or high-energy mechanism 1

Do NOT Routinely Order

• Foot radiographs (low yield except for fifth metatarsal base) 1
• Knee radiographs (low yield in isolated ankle injury) 1
• CT or MRI as initial imaging (reserved for specific indications) 1

Pain Management

Peripheral Nerve Blocks

Consider ultrasound-guided peripheral nerve blocks for superior analgesia: 1

• Popliteal sciatic and saphenous nerve blocks decrease postoperative pain intensity and opioid consumption compared to spinal anesthesia 1
• Single-shot blocks using 30-40 mL of 0.25% bupivacaine with epinephrine 1
• Reduces morphine consumption significantly (0.4 mg vs 19.4 mg, p=0.05) 1
• Increases patient satisfaction by 31% 1

Procedural Sedation

• Required for reduction of ankle fracture-dislocations 3
• Monitor continuously during and after sedation 3

Immobilization and Splinting

Initial Splinting

Splint the fractured ankle to reduce pain, prevent further injury, and facilitate transport: 1

• Splinting is useful even though evidence from prehospital settings is limited 1
• Splint in position found unless straightening is necessary for safe transport 1
• Apply posterior splint after reduction if indicated 3, 4

Reduction of Dislocations

• Perform urgent closed reduction under procedural sedation for ankle fracture-dislocations to restore anatomical alignment and prevent neurovascular compromise 3
• Document neurovascular status before and after reduction 3
• Obtain post-reduction radiographs to confirm alignment 3

Management Based on Radiographic Findings

If Fracture Identified

• Assess stability using weight-bearing views if not already obtained 1
• Stable fractures (Type B): Consider functional bracing with removable brace after initial week of splinting, which provides superior comfort (VAS 7.21 vs 5.74, p=0.02) and range of motion (49° vs 40°, p=0.00) compared to casting 5
• Unstable fractures: Orthopedic consultation for operative fixation 4, 6, 7
• Open fractures: Immediate operative management with irrigation, debridement, rigid anatomical internal fixation, and delayed primary closure at 5 days 4

If Radiographs Negative but Pain Persists

Order advanced imaging if pain persists >1 week with negative initial radiographs: 1, 2

• MRI without IV contrast OR CT without IV contrast are equivalent alternatives 1, 2
• MRI most sensitive for occult fractures and excellent for ligamentous injuries 2
• CT preferred for detailed fracture characterization 1, 2

If Radiographs Negative and Ottawa Rules Negative

• Imaging usually not appropriate for patients able to walk with negative Ottawa criteria 1
• Implement functional rehabilitation with NSAIDs, semirigid or lace-up ankle supports, and graded exercise with proprioceptive training 2
• Delayed physical examination at 4-5 days post-injury to assess ligament injury severity (anterior drawer test: 84% sensitivity, 96% specificity) 2

Critical Pitfalls to Avoid

Missed Syndesmotic Injuries

Test for high ankle (syndesmotic) sprains using crossed-leg maneuver, as these require different management and have longer recovery times 2

Premature Clinical Assessment

Do not rely on clinical examination alone in first 48 hours as excessive swelling and pain limit accurate assessment of ligament integrity 2

Elderly and High-Risk Patients

• Patients with poorly controlled diabetes and osteoporosis are at increased risk of wound complications, infection, and fixation failure 6
• Young active patients risk posttraumatic osteoarthritis with significant quality of life impact 6